Clinical Ethical Issues: Principles, Range of Cases, History Lessons

1
Clinical Ethical IssuesPrinciples, Range of
Cases, History Lessons

• Robert L. Perkel, M.D.
• Chair, Thomas Jefferson University Ethics
  Committee
• The 2nd Annual Healthcare Leadership Network of
  the Delaware Valley
• Spring Institute, May 2, 2014

2
Objectives

• To understand the principles that guide every
  ethics case discussion and dissection.
• To use case examples that describe clinical
  ethical issues at the beginning, in the prime,
  and at the end of life.
• To underscore the ultimate importance of
  professionalism with lessons from history

3
Bioethical Principles

• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Truth telling
• Informed Consent
• Confidentiality
• Futility

4
Practical Considerations

• Particular clinical facts of this case
• Attitudes and beliefs
• Culture of the patient physician
• Societal factors
• Demographics (aging)
• Finances (fixed GDP)
• Insurance (traditional v. prospective )

5
Ethics Case DiscussionWhat the HEC does

• Important players represented
• Case presentation facts data questions
• Discussion listen carefully weigh different
  opinions try on opposing viewpoints
• Arrive at option(s)
• Support with underlying principles
• Communicate to all the players
• Dont tell people what to do

6
Range of Cases HEC

• Ethics at the Beginning of Life
• Ethics in the Prime of Life
• Ethics at the End of Life
• Ethics of Professionalism

7
Ethics at the Beginning of Life

• Reproduction
• Human genome project
• Cloning
• Abortion
• The NICU technology imperative
• I can, therefore I do
• Use it or lose it
• Learning how and when to say No!
• Autonomy vs. Paternalism Justice
• Informed Consent

8
Ethics in the Prime of Life

• Dialysis plasmapharesis
• BMT for certain malignancies
• HIV/AIDs
• Autonomy vs. Social Justice
• Autonomy vs. Beneficence
• Competing Autonomies (Duty to Warn)

9
Bioethical Issues in HIV/AIDS

• Individual vs. Society
• patient autonomy vs. social justice
• Individual vs. Individual
• competing autonomies patient vs. provider
• End of Life/Medical Futility
• beneficence nonmaleficence
• Allocation of Resources
• social justice

10
Ethics at the End of LifeRefusing Life
Sustaining Treatmentvs. Requesting Assistance in
Dying

• 37 yo F Multiple Myeloma
• Failed Alkeran/Prednisone, VAD
• Im tired fed up ready to die
• No CPR, no antibiotics, let me die
• Keep me comfortable
• When the time comes, (help me die)

11
The Principle of Double Effect

• Long history, primarily but not exclusively in
  Roman Catholic tradition
• Supports claims that an act having a harmful
  effect such as death does not always fall under
  moral prohibitions such as the rule against
  killing
• There is a morally relevant difference between
  the intended effects of a persons action and the
  nonintended though forseen effects of the action

12
4 Conditions That Must Be Satisfied to Justify
Double Effect

• The action itself must not be intrinsically wrong
• The agent must intend only the good effect and
  not the bad effect
• The bad effect must not be a means to the end of
  bringing about the good effect
• The good result must outweigh the evil permitted

13
Helping Patients Die with DignityA Continuum of
Life/Death Issues

• Withholding life support
• Withdrawing life support
• Physician assisted suicide
• Active euthanasia
• Govt politics lessons from history

14
Let History Judge

• The Tuskegee Syphilis Experiment
• The Nazi Doctors

15
(No Transcript)
16
(No Transcript)
17
Objectives

• To understand the principles that guide every
  ethics case discussion and dissection.
• To use case examples that describe clinical
  ethical issues at the beginning, in the prime,
  and at the end of life.
• To underscore the ultimate importance of
  professionalism with lessons from history.